Basic Information
| Provider Information | |||||||||
| NPI: | 1760483770 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ELLINGTON MEMORIAL CLINIC, LLP | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ELLINGTON RURAL HEALTH CLINIC | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1011 SOUTH WILLIAMS STREET | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | TX | ||||||||
| PostalCode: | 755513245 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9037962868 | ||||||||
| FaxNumber: | 9037960826 | ||||||||
| Practice Location | |||||||||
| Address1: | 1011 SOUTH WILLIAMS STREET | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | TX | ||||||||
| PostalCode: | 755513245 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9037962868 | ||||||||
| FaxNumber: | 9037960826 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/02/2005 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | CARNEY | ||||||||
| AuthorizedOfficialFirstName: | ANITA | ||||||||
| AuthorizedOfficialMiddleName: | G | ||||||||
| AuthorizedOfficialTitleorPosition: | OFFICE MGR | ||||||||
| AuthorizedOfficialTelephone: | 9037962868 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | TX | N | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 261QR1300X | TX | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | 04709 | 01 | TX | BCBS | OTHER | 133389002 | 05 | TX | MEDICAID | 133389004 | 05 | TX | MEDICAID | 88966 | 01 | TX | BCBS | OTHER | 133389005 | 05 | TX | MEDICAID |